The prevalence of intestinal parasites, undernutrition and their associated risk factors among school‐age children in Sekota Town, Northeast Ethiopia: A community‐based cross‐sectional study

Abstract Background and Aims In developing countries, intestinal parasitic infections and malnutrition are among the most serious health issues affecting school‐aged children. They have synergetic consequences. This study aimed to determine the prevalence of intestinal parasites, undernutrition, and their associated risk factors among school‐age children. Methods A community‐based cross‐sectional study was conducted from April to June 2021 among school‐age children in Sekota Town, Northeast Ethiopia. Households were selected using a systematic random sampling technique. Risk factor variables were collected using pretested questionnaires. Stool samples were collected from study participants and examined using a wet mount, formol‐ether concentration, and modified acid‐fast techniques. The height and weight of children were also measured using a meter and a standard calibrated balance, respectively. Data were analyzed using SPSS version 26.0 statistical software. Results The overall prevalence of intestinal parasites among school‐age children was 44.3% (178/402). About seven species of intestinal parasites were identified. The predominant parasite identified was E. histolytica/dispar (11.2%), followed by H. nana (9.2%) and G. lamblia (6.7%). The well as a source of drinking water (adjusted odds ratio [AOR] = 7.93; 95% confidence interval [CI]: 4.38–14.36), habit of open‐field defecation (AOR = 7.02; 95% CI: 13.05–12.06), and being undernourished (AOR = 5.67; 95% CI: 2.98–10.79) were independent predictors of intestinal parasitic infections. On the other hand, the overall prevalence of undernutrition was 46.3%. Undernutrition was significantly more likely in children with a dietary diversity score (DDS) of 3 (AOR = 3.73, 95% CI: 2.37–5.88), meal frequency of no more than three times per day (AOR = 2.00, 95% CI: 1.71–2.98), intestinal parasite infection (AOR = 5.25, 95% CI: 3.24–8.52), and no access to school‐based feeding (AOR = 3.52, 95% CI: 2.17–7.96). Conclusion The prevalence of intestinal parasitic infections and undernutrition was high among school‐age children in Sekota Town. The results imply the need for strengthening integrated strategies for the reduction of intestinal parasitic infections and undernutrition.

suffering from the most severe type of malnutrition. 16 Stunting is prevalent in Sub-Saharan Africa, with a proportion of SAC impacted as high as 19.0%-26.0% in Ethiopia. 17 Despite the fact that Ethiopia has seen a steady and substantial decrease in stunting over the last decade, levels remain high, and stark geographical inequities exist.
Ethiopia's government declared on July 15, 2015, that it would abolish child malnutrition by 2030, reaffirming its commitment to nutrition as a cornerstone for economic development. So the country established the Seqota Declaration to attain this purpose. 18 Both intestinal parasitic diseases and malnutrition are common in underdeveloped areas. 9,19 Intestinal parasitic infections can cause malnutrition in children by consuming nutrients and damaging the intestinal mucosa, resulting in reduced digestion and nutritional absorption. On the other hand, malnutrition may be a risk factor for intestinal parasite infections. 20,21 School-age children's generally poor health status is being exacerbated by the synergetic effect of these illnesses, which are regarded as top global health challenges. 19,22,23 End epidemics of water-borne diseases and other communicable diseases by 2030, as stated in Ethiopia's Sustainable Development Goal 3. Ethiopia also pledged to reduce noncommunicable disease-related premature mortality by one-third through prevention and treatment, as well as promote mental health and well-being. 24 These types of studies are critical for evaluating programs in various parts of the country.
Furthermore, there is no information available on the nutritional status and intestinal parasitic infections of children over the age of five, particularly in the study area. So this study was conducted to fill these gaps. This study will increase the intersectoral collaboration of decision-makers in the areas of health and education. The findings of this study will be useful to the Sekota Declaration program, which has been working on stunting, as well as other concerned bodies.
Therefore, this study aimed to assess the prevalence of intestinal parasites, undernutrition, and their associated risk factors among SAC in Sekota Town, Northeast Ethiopia.

| Study area
This study was conducted in Sekota Town, Waghemra Zone, Amhara Regional State, Northeast Ethiopia. Sekota town is found 720 km from Addis Ababa, which is the capital city of Ethiopia. The town is situated at 2266 m above sea level, and its average annual temperature and rainfall are 29°C and 786 mm, respectively. The town is divided into four kebeles (the smallest administrative units next to the district in Ethiopia).
Based on the 2021 city administration report, it is home to about 41,696 people and 10,055 households. The town also has one hospital, one health center, and four health posts.

| Study design and period
A community-based cross-sectional study was conducted from April to June 2021.

| Eligibility criteria
Children who are 6-14 years old, who have lived in the town for at least 6 months, and who are willing to participate in the study were included. Children who are taking antiparasitic medication or nutritional supplements and whose guardian is unwilling to give written consent were excluded.

| Sample size and sampling methods
The sample size for this study was determined using a single population proportion formula.

| Sampling technique and procedures
Using data from the city administration as a sampling frame, stratified sampling was used to allocate the number of households to four kebeles based on their number of households. Based on the total number of households, study participants were proportionally selected from each kebele. The number of households assigned to each kebele was then determined using a systematic random sampling technique for every 24 households. Finally, one school-age child in a household was selected using the lottery method of random sampling ( Figure 1).

| Anthropometric measurements
The weight and height of each child were measured by clinical nurses using a digital weighing scale that measured to the nearest 0.1 kg and a vertical meter that measured to the nearest 0.1 cm, respectively.
The child's shoes, jacket, and hair clips were removed before measurement, and the children were positioned with their feet together flat on the ground, heels touching the back plate of the measuring instrument, legs straight, buttocks against the backboard, scapula against the backboard, and arms loosely at their sides. To reduce subjectivity error, study participants' weight and height were measured twice by independent nurses, and the mean measurement value was recorded. The WHO AnthroPlus software was used to calculate Z-score of height for age (HAZ) and body mass index for age Z-score (BAZ). Children with Z-score < −2 SD were classified as underweight (WHZ < − 2 SD), stunted (HAZ < − 2 SD) and wasted

| DISCUSSION
Intestinal parasites are a common public health concern in developing countries, with SAC being at higher risk. 29 In this study, the overall prevalence of intestinal parasites among SAC in Sekota town was 44.3% (95% CI: 38.6%-49.0%). This finding was higher than reports from Sekota town (30.0%), 30 Harbu town (21.5%), 12  Eritrea. 23 Entameoba histolytica causes amoebiasis, a potentially severe and life-threatening disease and the second most common cause of death from parasitic diseases after malaria. Cryptosporidium species and G. lamblia are also nowadays, a major cause of diarrhea, especially in children. 38,39 The predominance of E. histolytica/dispar and G. lamblia infection might be associated with poor hygiene, poverty, lack of access to portable water, and a hot, humid tropical climate. Furthermore, their infective stage (the cyst) can withstand a standard level of chlorine treatment in drinking water. 40 Hence, an unimproved source of drinking water might increase the risk of intestinal protozoan infections among SAC in the study area.
The prevalence rate for H. nana was 9.2%, which was consistent with earlier research. 19,23 This parasite can be transmitted from one child to the next by contaminated hands (external autoinfection) or reverse peristalsis. T. trichiura was also the only soil-transmitted helminthic parasite found in this study (4.7%). It causes different complications like enteropathy as a result ofchronic inflammation, which results in a leaky gut and poor nutrient absorption. 41,42 T A B L E 3 Binary logistic regression analysis of factors associated with intestinal parasitic infections among school-age children in Sekota Town, Northern Ethiopia, from April to June 2021. Environmental interventions, such as water, sanitation, and hygiene should be considered when designing nutritional interventions.
Intestinal parasites were eight times more likely to infect children who drank well water. This finding was consistent with other studies, which found that using a well as a source of drinking water increased the likelihood of protozoan infection. 23 Dietary diversity score, meal frequency, lack of access to schoolbased feeding, and parasitic infection were independently predicted undernutrition among SAC in this study. A similar association was reported between the dietary diversity score in Burkina Faso 49 and lack of access to school-based feeding in Mecha, Northwest Ethiopia, 47 showed a statistically significant association. Furthermore, meal frequency and being infected with intestinal parasites were predictors of undernutrition, which is in agreement with a study conducted in Bahir Dar, Ethiopia. 19 Intestinal parasitic infection competes for the nutritional intake of children and also impairs the immune system of the host, so that it makes them susceptible to many diseases.

| Limitation of the study
The limitation of the study was that we did not measure the intensity of the parasites, micronutrient intake, and red blood cell levels of the children due to a lack of laboratory equipment and reagents. As a result, we recommend that future studies of this type take into account the limitations mentioned above.
T A B L E 5 Binary logistic regression analysis of potential risk factors associated with under nutrition among school age children in Sekota Town, Nourtheast Ethiopia, from April to June 2021.

Risk factors Categories
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